Form Mc 361A is a document used to request an exemption from the individual shared responsibility payment for not having minimum essential coverage. This form can be used by individuals who have religious objections to health insurance, or who have other moral or ethical objections. In order to complete this form, you must provide documentation supporting your exemption claim. The IRS will review your application and notify you of their decision. If you are granted an exemption, you will not be required to pay the shared responsibility payment.
| Question | Answer |
|---|---|
| Form Name | Form Mc 361A |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | state court mc form, documents mc pdf, declaration fact mc form, 361a |
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
TELEPHONE NO.: |
FAX NO. (Optional): |
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ATTORNEY FOR (Name): |
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SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
IN THE MATTER OF
(Name):
DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF BIRTH
FOR COURT USE ONLY
CASE NUMBER:
HEARING DATE AND TIME: |
DEPT.: |
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(Name of declarant): |
declares as follows: |
1.I make the statements in this declaration based on my personal knowledge or on the contents of the documents identified in item 5. (“Personal knowledge” of a fact is knowledge that is not gained from another person's statements to you about that fact.)
2.a. I am at least 18 years of age.
b. I reside at (street address and city):
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3. (Name): |
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was born at |
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approximately (time of birth): |
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a. m. |
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p. m. |
on (date): |
at the following place: |
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a. City, town, township, or other (identify “other” if known): |
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b. |
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County: |
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State (U.S.): |
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c. |
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State or province: |
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Country: |
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4. Facts showing when and where the person named in item 3 was born and explaining how I have personal knowledge of those facts
are stated in the space below |
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are stated in Attachment 4 to this declaration. |
(If you are relying solely on the contents of the documents identified in item 5, please advise in the space below.)
Page 1 of 2
Form Adopted for Mandatory Use
Judicial Council of California
DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF BIRTH
Health & Safety Code, §§
(Miscellaneous)
IN THE MATTER OF
(Name):
CASE NUMBER:
5.
a.
b.
c.
d.
Attached are true and correct copies of the following documents (check each box that applies; statements of witnesses must be signed under oath, in an affidavit sworn before a Notary Public or with the following statement just above the signature:
“I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct”):
Hospital records dated (date of each):
Physician's report dated (date of each):
Witness statements dated (date of each):
Other documents dated (describe and give the date of each document; “Other documents” could include school or college records, vaccination certificates and other medical records, employment records, documents showing sources of support other than employment, family correspondence, diaries, photographs, and other similar family records):
Continued on Attachment 5d. |
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6. The birth of the person named in item 3, or the date, time, or place of birth |
is not |
is important to a court case or |
proceeding that is now pending and described below. (If you selected “is,” briefly describe the proceeding and provide the case name and number, the name and address of the court where the proceeding is pending, the names of all parties to the proceeding, and the names, addresses, and telephone numbers of their attorneys. Note: A court order made on a petition under Health and
Safety Code section 103450, et seq., may not be effective against claims of persons or organizations not given notice of the petition for the order.)
Continued on Attachment 6.
7.Number of pages attached:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME OF DECLARANT) |
(SIGNATURE OF DECLARANT) |
DECLARATION IN SUPPORT OF PETITION TO ESTABLISH
FACT, TIME, AND PLACE OF BIRTH
Page 2 of 2
(Miscellaneous)